NU176 | NU 176 Geriatric Nursing Exam 2 v3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. When assessing an older adult patient for signs of delirium, which assessment tool
should the nurse prioritize?
A. Geriatric Depression Scale (GDS)
B. Braden Scale
C. Confusion Assessment Method (CAM)
D. Katz Index of Independence
Correct Answer: C
Expert Explanation: The Confusion Assessment Method (CAM) is the gold standard
for bedside assessment of delirium in the clinical setting. It focuses on the four key
features of delirium: acute onset, inattention, disorganized thinking, and altered
level of consciousness. Using a validated tool like CAM helps nurses distinguish
between delirium, dementia, and depression quickly.
2. An older adult is diagnosed with stage II pressure injury on the sacrum. What
characteristic defines this stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of skin with exposed dermis
,C. Full-thickness skin loss with visible adipose tissue
D. Full-thickness skin and tissue loss with exposed bone
Correct Answer: B
Expert Explanation: A stage II pressure injury is characterized by partial-thickness
loss of skin involving the epidermis and/or dermis. The wound bed is typically
viable, pink or red, and moist, but may also present as an intact or ruptured serum-
filled blister. This stage does not involve the visualization of fat or deeper tissues,
which would categorize it as a higher stage.
3. Which of the following is a common atypical presentation of a Urinary Tract
Infection (UTI) in an older adult?
A. High fever and chills
B. Burning on urination (dysuria)
C. Flank pain and hematuria
D. Acute onset of confusion or agitation
Correct Answer: D
Expert Explanation: Older adults often present with non-specific symptoms of
infection due to physiological changes associated with aging. Instead of high fever or
localized pain, they frequently exhibit acute mental status changes, such as
,confusion or lethargy. Nurses must monitor for these behavioral shifts to initiate
timely diagnostic testing and treatment.
4. According to the Beers Criteria, which medication class should be avoided in older
adults due to the risk of falls and fractures?
A. Beta-blockers
B. Benzodiazepines
C. Proton pump inhibitors
D. Statins
Correct Answer: B
Expert Explanation: The Beers Criteria identifies medications that are potentially
inappropriate for the elderly, including benzodiazepines like diazepam or
lorazepam. These drugs increase the risk of cognitive impairment, delirium, and falls
in the geriatric population. Nurses should advocate for non-pharmacological
interventions for anxiety or insomnia before resorting to these high-risk
medications.
5. A nurse is educating a family about ‘sundowning’ in a patient with Alzheimer’s
disease. Which intervention is most effective?
A. Keeping the room dark during the late afternoon
B. Providing a heavy meal late at night
, C. Maintaining a consistent routine and adequate lighting
D. Administering a sedative as soon as the sun sets
Correct Answer: C
Expert Explanation: Sundowning refers to increased confusion and restlessness
during the late afternoon or evening hours. Maintaining a consistent daily routine
and ensuring the environment is well-lit can help reduce the patient’s anxiety and
disorientation. Minimizing noise and providing calming activities during this period
also contributes to better behavioral management.
6. Which type of urinary incontinence is characterized by the sudden, strong urge to
void followed by involuntary leakage?
A. Stress incontinence
B. Functional incontinence
C. Urge incontinence
D. Overflow incontinence
Correct Answer: C
Expert Explanation: Urge incontinence occurs when the detrusor muscle contracts
involuntarily, leading to an immediate need to urinate. This is often associated with
conditions like overactive bladder or neurological disorders. Management usually
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. When assessing an older adult patient for signs of delirium, which assessment tool
should the nurse prioritize?
A. Geriatric Depression Scale (GDS)
B. Braden Scale
C. Confusion Assessment Method (CAM)
D. Katz Index of Independence
Correct Answer: C
Expert Explanation: The Confusion Assessment Method (CAM) is the gold standard
for bedside assessment of delirium in the clinical setting. It focuses on the four key
features of delirium: acute onset, inattention, disorganized thinking, and altered
level of consciousness. Using a validated tool like CAM helps nurses distinguish
between delirium, dementia, and depression quickly.
2. An older adult is diagnosed with stage II pressure injury on the sacrum. What
characteristic defines this stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of skin with exposed dermis
,C. Full-thickness skin loss with visible adipose tissue
D. Full-thickness skin and tissue loss with exposed bone
Correct Answer: B
Expert Explanation: A stage II pressure injury is characterized by partial-thickness
loss of skin involving the epidermis and/or dermis. The wound bed is typically
viable, pink or red, and moist, but may also present as an intact or ruptured serum-
filled blister. This stage does not involve the visualization of fat or deeper tissues,
which would categorize it as a higher stage.
3. Which of the following is a common atypical presentation of a Urinary Tract
Infection (UTI) in an older adult?
A. High fever and chills
B. Burning on urination (dysuria)
C. Flank pain and hematuria
D. Acute onset of confusion or agitation
Correct Answer: D
Expert Explanation: Older adults often present with non-specific symptoms of
infection due to physiological changes associated with aging. Instead of high fever or
localized pain, they frequently exhibit acute mental status changes, such as
,confusion or lethargy. Nurses must monitor for these behavioral shifts to initiate
timely diagnostic testing and treatment.
4. According to the Beers Criteria, which medication class should be avoided in older
adults due to the risk of falls and fractures?
A. Beta-blockers
B. Benzodiazepines
C. Proton pump inhibitors
D. Statins
Correct Answer: B
Expert Explanation: The Beers Criteria identifies medications that are potentially
inappropriate for the elderly, including benzodiazepines like diazepam or
lorazepam. These drugs increase the risk of cognitive impairment, delirium, and falls
in the geriatric population. Nurses should advocate for non-pharmacological
interventions for anxiety or insomnia before resorting to these high-risk
medications.
5. A nurse is educating a family about ‘sundowning’ in a patient with Alzheimer’s
disease. Which intervention is most effective?
A. Keeping the room dark during the late afternoon
B. Providing a heavy meal late at night
, C. Maintaining a consistent routine and adequate lighting
D. Administering a sedative as soon as the sun sets
Correct Answer: C
Expert Explanation: Sundowning refers to increased confusion and restlessness
during the late afternoon or evening hours. Maintaining a consistent daily routine
and ensuring the environment is well-lit can help reduce the patient’s anxiety and
disorientation. Minimizing noise and providing calming activities during this period
also contributes to better behavioral management.
6. Which type of urinary incontinence is characterized by the sudden, strong urge to
void followed by involuntary leakage?
A. Stress incontinence
B. Functional incontinence
C. Urge incontinence
D. Overflow incontinence
Correct Answer: C
Expert Explanation: Urge incontinence occurs when the detrusor muscle contracts
involuntarily, leading to an immediate need to urinate. This is often associated with
conditions like overactive bladder or neurological disorders. Management usually
